Overview of Open Inguinal Hernia Repair
An abdominal wall hernia is when tissue inside your abdomen pushes through a weak spot in your belly’s wall. Inguinal hernias, which occur at an opening or weak spot in the abdominal wall, are the most common type of hernia, accounting for around 75% of all abdominal wall hernias. Generally, a hernia is composed of internal organs or fat, a protective sac of lining tissue called peritoneum, and skin or other tissue.
Hernias can be of two main types: reducible and irreducible. Reducible hernias allow the hernia’s contents to be pushed back into the abdomen either on their own or with some gentle pressure. Irreducible hernias, on the other hand, don’t let the hernia’s contents return to the abdomen.
There are two subtypes within irreducible hernias: incarcerated and strangulated. An incarcerated hernia can’t be pushed back into the abdomen, usually due to a small opening in the hernia. However, the herniated tissue still gets enough blood supply and doesn’t cause any obstruction or inflammation.
In contrast, a strangulated hernia is an irreducible hernia where the tissue doesn’t receive adequate blood, which causes damage or even death to the tissue. This condition progresses fast and demands immediate medical attention as it is a surgical emergency.
Anatomy and Physiology of Open Inguinal Hernia Repair
The inguinal canal is an area that is important to understand, especially for general surgeons. It’s a “passageway” located in the abdomen, between two openings, namely the deep internal ring and the superficial external ring. Think of the internal inguinal ring as a side-opening within the abdominal lining, while the external one is a middle-opening within the outermost layer of abdominal muscles. The distance between the two rings can vary from 4 to 6 cm in length and is usually cone-shaped in adults. However, in children, these two rings overlap on each other.
The “front wall” of the inguinal canal has skin, a layer just below the skin, and a tissue extending from the outermost abdominal muscle. Muscle fibers from the internal oblique, another group of abdominal muscles, also cover the outer part of the canal. The “back wall” consists of the inner abdominal lining, a thin tissue layer outside of the abdominal cavity, and the lining of the body cavity. It also includes a joining muscle piece from two abdominal muscles along the inner two-thirds parts of the back wall. The “roof” and the “floor” of the canal are formed by the arching muscle fibers, and the groove-like surfaces of the inguinal and lacunar ligaments, respectively.
The inguinal canal is used as a passageway for certain structures to traverse. In men, there is the spermatic cord, and in women, the round ligament passes through it. The spermatic cord comprises a tube that carries sperm, multiple blood vessels, nerves, lymph vessels, and a network of veins. The ilioinguinal nerve is also found in the inguinal canal, which enters between the external and internal oblique muscles but leaves through the superficial ring along with other contents.
When repairing a type of hernia (a condition where an organ pushes through an opening in the muscle or tissue that holds it in place) known as an open inguinal hernia, several structures are noticable. One is the iliopubic tract, a part of the fascia that starts from the front top part of the hip bone and courses towards the middle before joining the inner part of the Cooper ligament. This tract outlines the lower part of the internal ring and transitions into part of the femoral canal.
There are two kinds of inguinal hernias: direct and indirect. An indirect hernia, which is situated towards the side of certain blood vessels, happens when the intestine pushes through the internal inguinal ring. In contrast, a direct hernia occurs in an area of weakness within the inner fascia of the abdomen and is near to the bottom edge of the inguinal ligament, a part of a region called the Hesselbach triangle. If both types of hernias exist side by side, it’s known as a Pantaloon hernia.
Why do People Need Open Inguinal Hernia Repair
When a doctor suspects you have an inguinal hernia, which is a bulge or swelling in your groin, they’ll usually rely on their observation of your symptoms and a physical examination to confirm it. They might not need to use additional imaging techniques like a CT scan or ultrasound unless there are special circumstances that require it. For example, if there’s a possibility that your intestines are blocked, these imaging tests could be helpful. However, such tests aren’t always necessary before surgery if that’s the chosen treatment option.
Most of the time, inguinal hernias don’t cause any discomfort until a bump appears in the groin. Some individuals might feel pain when they exert themselves or lift heavy objects. Usually, larger hernias are the ones that bring about pain and discomfort, which might temporarily subside if pressure is applied to the swollen area or if the individual lies on their back while applying pressure. A physical examination includes checking both sides of the groin for any detectable lump or bulge that can either be pushed back into the abdomen or can’t be reduced. This examination should be performed in various positions like lying down, standing up, and during actions that put pressure on the abdomen like coughing or straining, since these can help expose smaller hernias that can be pushed back into the abdomen.
To diagnose a hernia during an examination, a doctor uses their index finger to gently push into the scrotum, getting close to the area just outside and above the pubic bone. During this part of the examination, coughing or straining can be critical because it pushes out any tissue that might be protruding and thereby helps the doctor confirm a hernia diagnosis.
In the world of surgeons, especially those specializing in children’s surgery, there’s an ongoing discussion about whether or not to examine and repair the opposite side of the groin when an inguinal hernia is detected on one side. Some surgeons choose to also explore the other side in children where there’s an increase in abdominal pressure due to extra fluid accumulation, like in kids with a shunt placed to relieve brain fluid buildup or those on peritoneal dialysis, which is a treatment for kidney failure.
When a Person Should Avoid Open Inguinal Hernia Repair
An open inguinal hernia repair is a common surgical procedure with no definite reasons why it should never be performed. Like all planned surgeries, it’s crucial for a patient’s health to be at its best before surgery. However, there are a few conditions which might make the surgery more challenging but not impossible:
1. If a person can’t tolerate general anesthesia (sleep-inducing medicine for surgeries), this might be a problem. The good news is that this procedure can also be done using local anesthesia (numbing only the area concerned without making you sleep).
2. If a person has a disorder that slows down the process of your blood clotting, known as Coagulopathy, surgery might be riskier.
3. If a person is extremely overweight, with a body mass index over 35, they will face more risks, complications and challenges during the surgery.
4. Current smokers also face more hazards during and after the surgery. So, if a patient is smoking, they should consider quitting before going for the operation.
Equipment used for Open Inguinal Hernia Repair
For this surgery, all that is needed is a basic set of surgical tools. The way this surgery is done can vary quite a bit, and this might mean we need some special equipment. But there are some essential tools we usually use, which include:
- A syringe and needle – for injecting fluids or collecting samples.
- A scalpel with a blade – the main cutting tool for the surgery.
- Electrocautery – a tool that uses electricity to cut tissues or stop small bleedings.
- Skin forceps and non-traumatic forceps – for gripping and holding tissues without causing harm.
- Self-retaining retractor – a tool that keeps the incision open during surgery.
- Metzenbaum scissor – a type of scissors used for cutting delicate tissues.
- Mosquito clamps – small clamps used to control bleeding.
- Penrose drain/Umbilical tape – used to remove fluid or pus from the wound after surgery.
- Needle driver – a tool for holding the suturing needle while stitching the wound.
- Mesh (optional) – a piece of material that might be used depending on the type of repair.
- Suture – thread used for closing the wound. They may be absorbable (they disappear over time) or nonabsorbable (have to be removed later).
Who is needed to perform Open Inguinal Hernia Repair?
For this type of medical procedure, typically one doctor, known as a surgeon, does the operation. However, there’s usually another person called an assistant to help out. Alongside, there is a specially trained nurse, referred to as either a surgical tech or a circulating nurse, who is also needed during the operation. There’s another crucial member in the team, the anesthesiologist. This is the doctor who makes sure you stay asleep and don’t feel any pain while the surgery is being done.
Preparing for Open Inguinal Hernia Repair
Before a doctor can repair an open inguinal hernia (a type of hernia that occurs when part of the intestine pushes through a weak spot in the abdomen), there are some important steps that need to be taken:
* Firstly, the patient’s overall health needs to be as good as possible ahead of the surgery. This ensures that the body can tolerate the procedure well.
* The doctor needs to clearly identify which side the hernia is on, both for paperwork purposes and for the actual surgery. This will also be marked on the patient’s body in the preparation area to avoid any errors.
* The patient will lie flat on their back on the operating table. Any hair at the surgical site will be removed and the area will be cleaned in a sterile manner to prevent infection.
* During the procedure, the leading surgeon will stand on the side where the hernia is located, while an assistant stands on the other side. This allows the team to work effectively together during the surgery.
How is Open Inguinal Hernia Repair performed
There are two main ways doctors can fix an inguinal hernia, which is a condition when an organ pushes through an opening in the muscle or tissue that holds it in place. These two methods are open and laparoscopic surgery. We’ll talk about open surgery here. If you’re interested in learning more about laparoscopic inguinal hernia repair, there’s another article dedicated to that topic.
In open surgery, the doctor makes a cut about 2 to 2.5 inches long in the area where the hernia is located, called the groin. The doctor then carefully separates different layers of tissue until they reach a section of muscle called the external oblique. They open this muscle in the direction that its fibers are running, in order to see the cord that carries sperm, which can sometimes be the site of the hernia.
At this point, they might also find a nerve called the ilioinguinal nerve. Some doctors choose to preserve this nerve, while others don’t – there’s a lot of varied opinions in the medical world about this, and it usually comes down to the specific doctor’s preference and their previous experiences.
Next, the doctor will identify whether an indirect or a direct hernia is present. A direct hernia sticks out through a weakened spot in your abdominal wall. An indirect hernia comes out through an opening in the groin. They will then repair the hernia by beautifully placing a mesh or non-mesh implant over the muscle defect to make that area stronger against future hernias.
There are a few well-known non-mesh repair strategies for hernias, including the Shouldice and Bassini methods. Shouldice repair gets a lot of praise due to its low rates of hernia recurrence or return. A systematic review – a type of study that combines the results of multiple studies – concluded that the Shouldice method is one of the best traditional ways to repair an inguinal hernia. The Bassini method involves stitching a muscle tendon to a ligament in the groin, which helps reinforce the area where the hernia was located.
Nowadays, most doctors use a mesh to repair hernias because studies comparing mesh to non-mesh procedures show that mesh repairs have lower recurrence rates and are less likely to accidentally damage important structures like blood vessels, nerves, and organs. Mesh repairs also typically result in shorter hospital stays. However, in developing countries where costs are a bigger concern and mesh might not always be readily available, non-mesh repairs are still common.
Possible Complications of Open Inguinal Hernia Repair
After a surgery to fix a hernia, the main worry is that the hernia might come back. This usually happens near the pubic bone, especially if the surgery technique wasn’t performed properly. It is also important for the patient to avoid heavy lifting or intense physical activity to prevent the hernia from returning. In children, hernias might recur if they have a slow wound healing ability. This could be linked to certain medical conditions that affect the body’s connective tissues, or how the body processes certain types of molecules.
It is also common for many patients to describe long-term pain after surgery. This is part of a bigger discussion about whether surgeons should try to preserve or sacrifice nerves during the hernia surgery. In some cases, nerves might be damaged during surgery, causing long-term discomfort or pain. That is why it’s important for surgeons to be careful with nerves during hernia surgery to try and reduce potential pain afterwards.
What Else Should I Know About Open Inguinal Hernia Repair?
An inguinal hernia is when tissue, like part of your intestine, pushes through a weak spot in your groin area. It can be very painful, especially when you cough, bend over, or lift a heavy object.
Usually, the best treatment for an inguinal hernia is surgery to fix the spot where the tissue is poking out. This surgery is typically done to prevent serious complications such as the trapped tissue getting its blood supply cut off (which is called strangulation).
However, it is still safe to watch and wait in elderly people who have a lifestyle that doesn’t involve a lot of physical activity or in people for whom surgery would carry a high risk.
This surgery can be done under general anesthesia (where you’re unconscious), sedation (where you’re relaxed but awake), and regional or local anesthetic (which just numbs the area).
After the surgery, the doctor will instruct the patient not to lift anything heavier than 10 pounds (4.5 kg) and to avoid any tough activity for at least 4 to 6 weeks.
The specific technique for this surgery can vary from case to case. Still, the overall aim is the same – to repair the weak spot where the tissue is coming out.
